Provider Demographics
NPI:1447676481
Name:STIDHAM, EILEEN (PTA)
Entity type:Individual
Prefix:
First Name:EILEEN
Middle Name:
Last Name:STIDHAM
Suffix:
Gender:F
Credentials:PTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:47 GOLDBRIAR WAY
Mailing Address - Street 2:
Mailing Address - City:MISSION VIEJO
Mailing Address - State:CA
Mailing Address - Zip Code:92692-5986
Mailing Address - Country:US
Mailing Address - Phone:949-285-3195
Mailing Address - Fax:
Practice Address - Street 1:1111 W TOWN AND COUNTRY RD STE 1
Practice Address - Street 2:
Practice Address - City:ORANGE
Practice Address - State:CA
Practice Address - Zip Code:92868-4635
Practice Address - Country:US
Practice Address - Phone:714-997-5518
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-03-14
Last Update Date:2014-03-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAAT-5906225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant